Advancing cancer research in Africa: Harold Stewart and the National Cancer Institute

Circulating Now welcomes Mark Parascandola, PhD, to discuss his research in the Harold Leroy Stewart Papers at the National Library of Medicine. Dr. Parascandola is Director of the Research and Training Branch at the National Cancer Institute’s (NCI) Center for Global Health.

In July 1950, scientists from around the world gathered in Oxford to discuss how cancer incidence varies by geography. While cancer had long been considered largely a problem of modern society, rarely seen outside North America and Europe, increasing reports highlighted unusual cancer patterns across Asia and Africa. For example, doctors working in Africa had reported very high rates of liver cancer among laborers working in gold mines, much higher than that seen elsewhere. Studying differences in patterns of cancer, it was thought, could provide clues to the causes, and potential prevention, of cancer via a new field of study named “geographic pathology.” As the New York Times reported, for the scientists gathered in Oxford “all the world is a laboratory, and the people are their guinea pigs.” At the end of the meeting, the group identified liver cancer, particularly in Africa, as a top priority.

One of the champions of this new field was Dr. Harold L. “Red” Stewart, Chief of NCI’s Laboratory of Pathology. Stewart had been with NCI since its establishment in 1939 and had been conducting experimental laboratory studies in rats to understand different types of tumors and how they developed. But he recognized that laboratory findings would now have to be tested in human populations. Stewart established a Unit on Geographic Pathology of Cancer at the NCI that would serve as a hub for international collaborations. He recognized that adequate research facilities and surveillance infrastructure were lacking in many parts of the world, but envisioned a global network of pathologists exchanging data and information, greater than the sum of their parts. Over the next decade, Stewart corresponded with pathologists and cancer researchers around the world, and his personal papers at the National Library of Medicine (NLM) provide a window into the development of early global cancer research efforts.

In December 1951, at a meeting of the International Cancer Research Commission in Lisbon, Stewart met Joseph Gillman, an accomplished South African doctor and researcher who had recently been appointed Wits Chair of Physiology at the University of Witwatersrand. Gillman had been studying nutrition and cancer in rats. Gillman told Stewart that cancer received little attention in South Africa relative to other seemingly more pressing health challenges, but that the country offered unique opportunities for cancer research. The mix of European and African populations and contrast between rapidly modernizing urban areas and traditional tribal lifestyles and customs offered an opportunity to study the potential influence of race, environment, and lifestyle on cancer. Stewart encouraged Gillman, along with his colleagues John Higginson and Alfred George Oettle at the South African medical Research Institute, to apply for a research grant from the NCI.

Previous reports on cancer incidence in Africa had been primarily based on hospital autopsies, but this likely missed many cancers in people who died outside the hospital or who died of other causes. Higginson and Oettle sought to improve on this by conducting a thorough survey of all cancer cases identified around Johannesburg, engaging local clinics and hospitals that provided free medical services to both European and native populations. After two years, the NCI-funded study showed that the rate of liver cancer among indigenous South Africans was five to ten times higher than that seen in Europe and the US. The study was one of the first cancer surveys conducted in Africa (another survey was being conducted in Kampala, Uganda, at the same time funded by the British Empire Cancer Campaign) and it marked the first time a National Institutes of Health grant had been awarded to researchers in Africa.

Early cancer researchers working in Africa faced many challenges. It was not just a matter of limited equipment or funds, Higginson wrote to Stewart: “The real major handicap for all research projects in Africa is the lack of trained staff.” Doctors and technical staff were too overwhelmed with routine clinical duties to be enlisted in organized research efforts.  When the Union Internacional Contra Cancer (UICC) and the World Health Organization (WHO) proposed ambitious plans to expand collection of cancer data at hospitals across Africa, Higginson warned that such an effort was bound to fail, as the additional burden on local staff would strain already overwhelmed resources.

When the UICC established a Committee on Geographic Pathology, Stewart served as its Chair for ten years. The Committee took a special interest in Africa and organized some of the first international meetings on cancer there. In 1956, a series of three meetings in Kampala, Leopoldville (Kinshasa) and Dakar brought an international delegation of scientists to Africa. There were efforts across the continent to initiate cancer surveys and research activity, including in Senegal, Uganda, Mozambique, Nigeria, and Ghana, in addition to South Africa. Over the following decade, Stewart had regular correspondence with cancer researchers across Africa, providing expert guidance, professional advice and sometimes managing disagreements. As Chair of the Committee, Stewart also served in a diplomatic role, negotiating and helping to resolve conflicts between the UICC and WHO, colonial governments, and local institutions in Africa. Few medical researchers in Africa at the time focused on cancer, and those who did often worked in isolation, so Stewart served as a sounding board and vital connection to the international cancer research community.

In August 1960, Gillman wrote to Stewart to ask for advice as a friend. He had become increasingly distraught by the political environment in South Africa as Apartheid policies intensified. He wrote: “I find the situation morally intolerable and have no alternative in my own mind but to leave work here. The situation has been reached where there is nothing that any white person can do which is of a positive nature.” Gillman was struggling with the decision to leave, as he had lived his entire life in South Africa and spent twenty years building a research program and laboratories that were unparalleled in Sub-Saharan Africa at the time. In the end, he chose to stay in Africa and took a position as head of the new National Institute of Health and Medical Research (NIHMR) in newly-independent Ghana. His first action was to travel to Bethesda to seek advice from Stewart and others in setting up a research laboratory. NCI went on to develop a joint research laboratory with the NIHMR in Ghana, contributing NCI staff and resources over the next few years.

By the mid-1960s, the enthusiasm for geographic pathology had slowed. Large scale epidemiologic studies gained greater prominence for studying the causes of cancer. Many of the researchers who had led work in Africa left for Europe or North America, as opportunities for developing a cancer research career in Africa remained limited. Higginson would later go on to serve as the first director of the International Agency for Cancer Research in Lyon, France. And Stewart stepped down as Chair of the Committee on Geographic Pathology as priorities at NCI shifted towards epidemiology and clinical studies.

Cancer research in Africa would pick up again later. Today, many U.S. cancer centers have research programs in Africa, building on research infrastructure and capacity that developed around HIV/AIDS. However, Stewart’s personal papers provide a unique window into early efforts to establish cancer research activity in Africa and some of the challenges faced at a critical time.

Mark Parascandola, Ph.D., M.P.H., is Director of the Research and Training Branch in the Center for Global Health at the National Cancer Institute (NCI). He has authored over 75 published articles on global cancer prevention, implementation science, tobacco control, and epidemiologic research methodology.